Provider Demographics
NPI:1578041919
Name:JOHNSON, MICHAEL BLAINE (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLAINE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2848
Mailing Address - Country:US
Mailing Address - Phone:608-436-9182
Mailing Address - Fax:
Practice Address - Street 1:416 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6310
Practice Address - Country:US
Practice Address - Phone:608-365-1244
Practice Address - Fax:608-365-4097
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3648-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42117900Medicaid